H-Diplo Roundtable XXII-52
Luke Messac. No More to Spend: Neglect and the Construction of Scarcity in Malawi’s History of Health Care. New York: Oxford University Press, 2020. ISBN: 978-0190066192 (hardcover, $74.00).
2 August 2021 | https://hdiplo.org/to/RT22-52
Editor: Diane Labrosse | Commissioning Editor: Alden Young | Production Editor: George Fujii
In economic history and development studies it is common to compare societies according to per capita GDP, despite substantial work demonstrating the inadequacy of these metrics. In a recent paper, Stephen Broadberry and Leigh Gardner argue that a comparison between pre-industrial Europe and contemporary Africa can offer productive insights into levels of productive capacity and the sustainability of consumption. Broadberry and Gardner use this comparison to argue that “many African countries today are at a level of development similar to Europe in the medieval and early modern periods.” A careful reading of Luke Messac’s wonderful new book helps us to understand the danger associated with these types of analogies. Afterall, the naturalization of the comparison between medieval Europe and contemporary Africa encourages the belief that “inadequate public-sector health-care funding, poorly trained medical staff, and outdated drugs and equipment are, in this formulation, a necessary consequence of a low GDP” (3). In the study of African development, there is a strong tendency to emphasize what Luke Messac terms ‘the macabre’ or the idea that in poor societies limited resources demand that someone has to make the tough decisions about who lives and who dies.
A sense of outrage frames Messac’s book, as he uses his experiences as practicing medical professional as well as a Ph.D. in the History and Sociology of Science to argue that Malawi’s tragedy is not a case of “inevitable poverty but rather of malign neglect.” Messac acknowledges that scarcity for any material resources is a real constraint. According to the International Monetary Fund in 2016, Malawi had the second-lowest nominal GDP per capita in the world (5). However, Messac persuasively argues that only a myopic reading of Malawi’s history would accept that a country should only be able to spend its domestic resources on vital services for its citizens as though “foreign flows of wealth did not exist” (5), an argument recently given new heft by the intrepid historical scholarship of Vanessa Ogle, who has demonstrated the huge scale of extraction by colonial and settler investors at independence in the case of countries like Malawi. Messac uses archival and ethnographic research to denaturalize the relationship between scarcity and the provision of adequate health care, restoring the link between power relations at the global scale and domestic political choices.
Over seven roughly chronological chapters Messac tells a story of the “rhetorical and political work required to sustain a regime of delay in Malawi’s government medical care” (26). This history begins in the 1920s when Nyasaland became a central source of labor for the British military’s carrier service. In chapter 2 and chapter 3, Messac discusses colonial justifications for the neglect of the provision of healthcare. While chapters 4 and 5 look at the role that healthcare played in the developmental ideologies of the post-Second World War era. Chapter 6 is a fascinating story of the ways in which Malawi’s first Prime Minister, Kamuzu Banda, was able to use healthcare as part of his ideological infrastructure, while chapter 7 studies the ways in which the decay in Malawi’s healthcare infrastructure eventually contributed to crisis of the AIDS epidemic.
Geoffrey Traugh argues that Messac’s book proves that there is no such thing as a “reasonable” level of care that explains the poor health outcomes in Malawi. Rather, Messac demonstrates that what is “reasonable” is always a political rather than a technical question. Sarah Runcie points out that one of Messac’s contributions is his demonstration that “the social construction of scarcity becomes not the project solely of a colonial administration, a postcolonial dictator, or neoliberal international institutions, but rather a long-term endeavor” (22). Runcie goes on to point out that Messac’s book provides a useful guide for how to write the history of postcolonial Africa as new archives continue to become available. Finally, Elisa Prosperetti points out that No More to Spend is a “micro-global history of pointed neglect.” Prosperetti nevertheless wonders about the politics of language at play in Messac’s work, highlighted by the choice of scarcity rather than austerity with its perhaps more deliberate attention to intentionality. She goes on to point out that the construction of scarcity in Malawi also points out the underdevelopment of the public as a viable category of Malawian political life. In this way all three reviewers point out how a past of neglect in terms of the provision of healthcare in Malawi continues to haunt the present. Finally in his response, Messac offers a number of reflections on his framing concept of scarcity. Pushed by Prosperetti’s comments, Messac ventures that scarcity and austerity have different meanings, scarcity referring to natural limits, austerity by contrast referencing periods of profligacy. Messac points out that scarcity is the term that haunted bureaucratic discussions of provision of medical care pushing to the margins the voices raised by Runcie and Traugh, who highlight the possibilities of remaking Malawi’s economy. In the end, Messac and the contributors to this roundtable all highlight the poverty of imagination that has consigned places like Malawi to inadequate medical care.
Luke Messac is a Senior Resident in Emergency Medicine at Brown University. He received his M.D. and Ph.D. from the University of Pennsylvania. His work focuses on the history and political economy of medical care in Africa and the United States. He is at work on a history of medical debt collection.
Alden Young is Assistant Professor of African American Studies at the University of California, Los Angeles, where he teaches the Program in International Development Studies. He is the author of Transforming Sudan: Decolonization, Economic Development and State-Formation (Cambridge University Press, 2017).
Elisa Prosperetti is a Visiting Assistant Professor in the History Department at Mount Holyoke College. She works on the history of education in Ghana and Côte d’Ivoire. Her publications have appeared in the Journal of African History, History in Africa, and Ghana Studies.
Sarah Runcie is Assistant Professor of History at Muhlenberg College. Her research focuses on histories of public health and decolonization in Cameroon.
Geoffrey Traugh is a Harper-Schmidt Fellow in the Society of Fellows in the Liberal Arts and a Collegiate Assistant Professor in the Social Sciences Division at the University of Chicago. He is currently working on a manuscript on how and why development went rural in post-colonial Africa. His work has appeared in the Journal of Southern African Studies, History in Africa, and Politique Africaine.
No More to Spend opens with a tragedy. Innocent, a teenage boy, is hit by a stray bullet as he accompanies his sister home from school in early 2015. The utterly avoidable result—in Malawi’s under-resourced health care system—is the loss of his leg, and calamity for Innocent and his family. When we learn that Messac has changed the names of his Malawian interlocutors (23), it becomes clear that the tragedy of “Innocent” is a synecdoche for the tale Messac narrates. Events which are unconcerned with the residents of places like Nyanza and Neno—from the discovery of South Africa’s mineral wealth to the rise of American Protestant evangelicalism—directly shape the health care possibilities available in Nyanza and Neno. In what is a micro-global history of pointed neglect for Malawi’s “Innocents,” No More to Spend impugns the myriad actors who have valued the paradigm of “scarcity” more highly than the lives of ordinary people in the world’s second poorest country (5).
As the preceding description implies, the book is a work of academic activism. The stakes here are profound, and Messac, a practicing doctor, refuses to let the patina of a discredited academic ‘objectivity’ cover them up. One way in which the author conveys the urgency of his argument is through the inclusion of stories, like Innocent’s, from the ethnographic present. These preludes to each chapter drive home how obstinately intertwined the past and the present really are. Another method, gracefully deployed, is the author’s writerly talent. Now that I have read chapter 3, I will never be able to think about the Colonial Welfare and Development Act (1940) as anything but a “dividend of disquiet” (82).
Another beautiful turn of phrase captures the object of the book’s focus: the “ethos of extreme economy” (32) that has characterized spending on Malawian health care since the 1880s. For Messac, this “ethos” has obviated critical engagement with resource distribution. From the late nineteenth century to the early twenty-first, a long cast of characters has taken for granted that resources to care for Malawi’s sick were simply not available—even as money continued to pour into capital-intensive projects. Whether those were “colonial follies,” such as the Trans-Zambesi Railway (1919), or postcolonial whims, such as former President Hastings Banda’s move of the capital city from Zomba to Lilongwe (1974), these flashy endeavors consistently took precedence over medical staff and supplies.
While reading, I was reminded of Walter Rodney’s feigned incredulity regarding British thrift in colonial schooling: “It is amazing that Northern Rhodesia with its immense copper wealth did not have enough money to educate Africans!” Rodney, writing in a different era, tempered nothing about his politics. Such ideological brashness has long fallen out of fashion, yet I found it curious that for all its activism, somehow politics have slipped out of No More to Spend. The heart of No More to Spend is a critique of resource distribution, but the language of materialist analysis is studiously avoided (Jürgen Habermas and Pierre Bourdieu are cited in passing). This observation raised a question for me regarding Messac’s choice of the word ‘scarcity’ over ‘austerity’ in the title (‘austerity’ appears five times in the text). Particularly in the wake of the 2008 financial crisis in Europe, ‘austerity’ conveys a critique of budgetary decisions made in the interest of those who control the purse strings—which appears to be the thrust of the book. ‘Scarcity,’ on the other hand, carries a different political valence, one that is shorn of class interests. In the Introduction, Messac links his use of “scarcity” to a 2005 conference at the University of Sussex (9), but I wondered: was the choice of “scarcity” (akin to “development”) an example of James Ferguson’s “anti-politics machine” at work?
A secondary argument accompanies the “construction of scarcity” thesis. Messac traces how health care provision has been mobilized as a source of political legitimacy. European missionaries provided medical care in order to support their conversion efforts, colonial officials claimed to be fulfilling promises of “trusteeship” by staffing clinics, and white settlers sought to prolong empire by highlighting the expansion of medical services they had facilitated in the Central African Federation (CAF). Banda, too, succumbed to pressures to eliminate user fees for medical care after just three months of imposing them. At the head of an independent country, he simply could not compare so unfavorably to the settler-dominated CAF regime.
While I found this argument appealing, I would have appreciated a discussion of what it is in particular about health care that curries legitimacy, and how that legitimacy stacks up to other imperatives of the modern state. It is here that I should reveal my cards: I write as a specialist not of Malawi and not even of medicine, but rather a historian who focuses on public education in West Africa and, as such, eyes government spending closely. I share Messac’s “retrograde” (10) instinct to consider budgets to be valuable historical sources—not for their precision, exactly, but for what their breakdowns can tell us.
Doing so has revealed to me that education was the category of public spending that best helped shore up political authority, at least in the parts of postcolonial Africa that I study. But the trend appears to hold for Malawi too. In 1978, health accounted for only 5.3% of the central government budget in Malawi, whereas education claimed more than double that (11.8%). If health services were as, or more, important than education in securing political legitimacy, the numbers should be the inverse. Indeed, when Bakili Muzuli took power from Banda in 1994, Messac tells us that his “most popular move” (177) was to eliminate tuition fees for primary schools—not to dramatically expand health care provision. The same emphasis on education over health spending shows up in the Colonial Welfare and Development Act, where the “only category of funding that received a larger amount [than health] was education” (105). Education and health are often thrown into the same category: the dreaded bottomless pit of social services. I invite Messac to think through what makes them analytically distinct, in order to fully realize the argument tying legitimacy to medicine. As the author himself writes: “[i]n any study of budgetary priorities, it is necessary to look not only at a single line item…but also at those line items that claimed significant shares of available resources” (68). I fully concur. Three cheers for the budding historiography of budgetary priorities!
Beginning its territorial life as a holding of the British South Africa Company, Malawi was consistently denied even the semblance of governance for the public good. The times when health spending has been highest, in 1962 under Federation rule and in the first decade of the 2000s with George W. Bush’s President’s Emergency Plan for AIDS Relief (PEPFAR), it has been due to external agents. Over more than a century, the state’s lack of accountability for the health of the people it governs has been shielded by the “construction of scarcity.” And yet, I wonder whether the book’s subtitle does justice to its powerful contribution. In my reading, there is another construction project hiding just out of sight. No More to Spend underscores how scarcity has undermined the notion of the ‘public’ in African (post)colonies, which were brought into being on the premise of private profit. Through the lens of health spending, we glimpse that the creation of a meaningful ‘public’ is still under construction. Messac’s text is an autopsy of that as-yet-unrealized project in Malawian history.
Luke Messac’s book, No More to Spend, effectively destabilizes the language used to explain paltry health budgets and biomedical resources in Malawi beginning in the colonial period (when the territory was Nyasaland) and continuing to the present day. Messac argues that “scarcity” is not merely a descriptor of an unchangeable reality of healthcare in Malawi, but rather it is a language of justification for health inequities. Moreover “scarcity is a construction that obscures unequal wealth and exploitative extraction, and by so obscuring it aims to free the powerful from social obligations” (189). The construction of this idea of scarcity, Messac shows, is deeply rooted. He charts how both colonial and postcolonial officials used the language of having “no more to spend” through shifting political circumstances.
One of Messac’s key methodological moves is to reject this discourse as representing a self-evident state of affairs. Messac warns that historians run the risk of uncritically reproducing this logic of officials through their use of government archives (6). He looks closely at the debates that determined budgets for health care and, importantly, at the broader political economy that shaped these debates. Moreover, Messac asserts the need to look beyond such debates in order to analyze the on the ground impact. In a striking example, he shows how health spending doubled in Nyasaland as it entered into a Federation with Rhodesia, but the spending in practice represented the priorities of the white supremacist settler government (131).
As a historian who is also conducting research on medicine in post-colonial Africa, I found chapter 6 of the book, which focuses on the period of 1964-1982 and on the presidency of Hastings Kamuzu Banda, to be a particularly important contribution to the existing literature. Messac points out that “the historiography of medicine in postindependence Malawi is much thinner than that of its colonial precursor, Nyasaland” (147). The same is true of many other African countries. As post-independence archives increasingly become available in many places and historians of health are giving more attention to this period, Messac’s work will help shape this historiography in significant ways. As Messac points out for the period after 1980, government archives in Malawi are not yet open to researchers. This more contemporary period has also garnered more recent attention from medical anthropologists, among others, and Messac turns to this rich secondary literature to chart “continuities and discontinuities” to the present day in the book’s final chapter (171).
Messac’s focus on the period of early independence brings fresh insights and bolsters his argument that “the social construction of scarcity becomes not the project solely of a colonial administration, a postcolonial dictator, or neoliberal international institutions, but rather a long-term endeavor” (22). Chapter 6 shows Banda vocally supporting investment in health care and drawing on notions of kinship, fertility, and “wealth-in-people” to do so (160). Messac argues, however, that Banda’s commitment was often symbolic and did little to change Malawi’s standing in international health indices (168). Importantly for the existing literature on this period, Messac shows that Banda (a physician himself) did understand healthcare as a potential political liability and recognized that neglect could threaten his hold on power. Banda also translated biomedicine into a political topic through specific cultural frameworks. As he particularly drew on the symbolism of fertility, Banda’s pushback on population control programs promoted by the World Bank provides an interesting contrast to recent scholarship by Jennifer Johnson on the embrace of family planning programs in 1960s Tunisia. Messac’s interventions will undoubtedly shape these kinds of comparative discussions as scholars continue to write histories of health and medicine in 1960s and 1970s Africa.
One aspect of Banda’s rule that seems key to understanding this moment of health care and decolonization is his promise during negotiations regarding independence that Malawi would be “self-reliant” and free from British aid within ten years (142). Early on in the book, Messac suggests that the idea of “self-sufficiency” was an enduring construction of colonial rule (7). By reaffirming the idea that healthcare in Malawi was generated within colonial or national boundaries rather than by its position within an international political economy, this idea was a key companion to that of scarcity. As he sought to fulfill this promise of self-reliance, Banda in turn courted funds from a variety of international sources (164). Messac suggests that this seeking of international funds was itself a display of national sovereignty since Banda did not have to rely on “any single outside power.” (164) This kind of rhetorical construction of self-reliance does not assume detachment from an international arena but rather primarily a severing of the colonial relationship. I would be interested to see this argument about sovereignty and medicine in the era of decolonization further elaborated. I’m curious in particular how the idea of Malawian self-reliance in medicine compared to this idea in other areas of governance. And to what extent did the priorities of these international funders shape the use of healthcare funds in Malawi? Messac touches on these questions, but the book suggests a complexity of both intellectual and institutional history that would merit further exploration.
Another very rich section of chapter 4 analyzes British justifications for not extending new postwar investment in social services to African colonies that relied on the argument that African kinship networks provided a built-in social safety net. As shown in chapter 5 on the Federation of Rhodesia and Nyasaland, white supremacist ideology shaped justifications for inequity during this political period. I would be interested to hear more about the afterlife of these cultural and racist constructions of Malawians in the neoliberal framing of health care through ideas such as “cost effectiveness” in institutions such as the World Bank and the International Monetary Fund (IMF). Messac concludes near the end of the book that the construct of scarcity persists “because we continue to live in a world where nationality, language, class, race, gender and proximity hold great influence over our willingness to care about the lives of other human beings” (191). The book raises questions about the processes that rendered inequities that were historically rooted in colonialism and racism into this bland language of “cost effectiveness.” How did ideas about Malawi and Malawians figure into Banda’s interactions with institutions like the IMF and World Bank and the implementation of structural adjustment programs?
Messac makes clear, particularly in the conclusion, that he hopes for this book to not just enrich existing historical literature but also to push clinicians, researchers, and policy makers to reject status quo logics of healthcare scarcity. He also calls for other historians of health to take a much more oppositional stance towards this logic (192). Messac offers a model for doing so by not just examining the construction of the idea of having “no more to spend” but also uncovering when historical actors effectively challenged this idea. He highlights both social protest and the work of “elite reformists” (13) as drivers of increased healthcare spending at different historical moments. In this group of elite reformers, he includes both colonial-era European doctors who pushed for more resources and Malawian doctors in the post-independence period. A final set of questions concern the significance of thinking about these actors as a group. First, what are the limits of thinking through the lens of continuity from the colonial to the post-colonial in understanding the role of “elite reformists”? Messac unites these actors through their skepticism toward scarcity, while recognizing that some colonial doctors also supported colonial regimes. In thinking about Messac’s political economy framework for understanding healthcare, how might we understand those who challenged medical scarcity versus those who challenged the extractive colonial economies that created this scarcity? Similarly, in the post-independence period, were there political challenges within Malawi to austerity programs that would be helpful in broadening the scope of actors challenging scarcity? Messac concludes that the construction of scarcity “cannot be overcome by doctors and nurses alone” (191) and suggests a much broader consideration of the kinds of actors that shape the perceived possibilities of medicine. As a great book does, Messac’s work offers fresh framings and evokes questions as well.
In 1978, the head of the Department of Obstetrics and Gynecology of Queen Elizabeth Central Hospital (QECH) in Blantyre, John David Chiphangwi, escorted Life President Kamuzu Banda on a tour of the wards, with party officials and the press in tow. Chiphangwi did not dress up the rooms and hide away patients, as was customary for one of Banda’s visits. Instead Chiphangwi showed Banda the wards as they were—understocked, understaffed, and overwhelmed with people in need of care. As Luke Messac writes in his important new history of health care in twentieth-century Malawi, Chiphangwi took a serious risk with his tour, not only for himself but for the staff as well, some of whom up and left once they realized what Chiphangwi was planning to do. Banda had had people detained—or worse—for far less. But Chiphangwi’s gamble paid off. After the tour, Banda pledged to address conditions at QECH, and in the weeks that followed, the staff received some of the medical supplies and equipment they desperately needed.
Messac shows that Chiphangwi’s brave protest at QECH was part of a decades-long popular struggle for a health-care system that met the needs of ordinary Malawians. Messac, writing as a historian and a physician, tells the story of medical professionals like Chiphangwi who fought for more hospitals and clinics and for higher standards of care. They confronted governments and later international lending agencies that insisted, in the words of one colonial official from whom Messac takes his title, that Malawi had “no more to spend.” Messac argues convincingly throughout the book that there was in fact more to spend. For much of the colonial era, the largest line item on the territorial budget was the annual debt payment to Nyasaland Railways, which built and administered a railroad in the Southern Province that mainly served to enrich foreign investors. Colonial officials resented the payments to Nyasaland Railways. But they were equally resentful toward colonial health advocates and African activists who called on the government to do more to improve the territory’s health-care system. The same could be said of Malawi’s postcolonial governments. No one in Lilongwe relished making debt payments to the World Bank and other lenders, which at the height of structural adjustment laid claim to Malawi’s budget, just as Nyasaland Railways had done in the colonial era. That did not mean that government officials would countenance claims by health-care workers on the budget, however.
Doctors and nurses have historically made the best of difficult conditions, devising ways of making medical supplies and equipment last longer to meet the needs of their patients. According to Messac, improvisation has been part of the problem with health care in Malawi, and by implication, the Global South as a whole. His core argument is that these efforts at triage have contributed to what he terms the “social construction of scarcity” (18-19). Governments and lending institutions have refused to spend more. Health-care workers have come to expect less than what they need. And as a result, standards of care have become tied to what policymakers believe a country could reasonably afford rather than what medical professionals could actually provide. Scarcity has taken on a logic of its own, as the inadequacy of care became an excuse for low spending. That logic of scarcity is why, for instance, an expatriate doctor could suggest in the pages of the Malawi Medical Journal in 2003 that people living with HIV should be barred from government employment rather than cared for as persons with a treatable disease, in an episode that Messac describes in his last chapter on health care in contemporary Malawi (176-77).
No More to Spend shows that at key moments, governments—both colonial and postcolonial—have tried to break with scarcity. Messac argues that governments have tended to increase health spending in response to protests. These protests have taken different forms. Some have emanated from reformists within the government or the medical profession itself. Chiphangwi’s tour of Banda around QECH in 1980 is one such example. Looking back to the colonial era, Messac also discusses the local officials who lobbied the colonial administration to invest in health care for the African population, set against the backdrop of the rise of the British welfare state after World War II. He demonstrates that ordinary Malawians were discerning users of new local health services introduced by the Nyasaland government, actively seeking out the most effective forms of care. Colonial officials took note, and so during the high tide of anti-colonial protests in the late 1940s and 1950s, they spent liberally (by their standards) on health care. It was no coincidence that the Central African Federation—the short-lived, settler-ruled political union of colonial Malawi, Zambia, and Zimbabwe—poured money into territorial health-care systems. As Messac points out, even if spending did increase, the actual numbers fell well short of pledges, and the standard of care remained poor. Messac brings these stories together in chapter 5, offering a compelling reinterpretation of the anti-vaccine protests of 1960 as a refusal of ineffective medicine from an illegitimate government, as opposed to a revolt against care itself. The protests have continued since independence in 1964, with medical professionals and ordinary Malawians fighting for better access and quality of care for all.
Messac makes a powerful case for reimagining health care in contemporary Malawi. Scarcity, he argues, is not an inevitability, but part of a long history of neglect that began with British colonialism. Here Messac echoes the sentiments of Malawian nationalists in the crucial years around the Emergency of 1959, who insisted that an independent Malawi could support itself and provide for a better life for its people. The problem was the budget, not Malawi—the British were dumping money into police and security in hopes of salvaging the white-minority-ruled Central African Federation, driving the territory into debt. Messac is also firmly within the best tradition of Malawian historiography, which for all its criticism of Banda and the Malawi Congress Party, has taken inspiration from Congress’s late-colonial era slogan—that Malawi was neglected, not poor. He shows that Malawi’s poverty has been a matter of political choices—to construct an uneconomical railway, to fund repressive security forces, to invest in vanity projects—rather than its people. Messac’s focus on these choices, as well as the continuities across the colonial-postcolonial divide, adds a welcome policy and political-economic dimension to the literature on health and medicine in Malawi.
Messac urges readers to rethink what counts as “reasonable” (192) care in Malawi and the Global South. While he is never quite prescriptive in his conclusions, his ethnographic vignettes gesture toward an argument for a universal standard of care, as he describes how cases that would be routine in the United States can become debilitating or even life-threatening in Malawi. From the vignettes, it is possible to see why improving care has historically involved both elite and popular protest. Though Malawians have not been socialized into scarcity, as Messac argues (189), a history of inadequate care can make it difficult for ordinary people to imagine what they might be denied, if only for lack of familiarity. That is where medical professionals can contribute to reimagining care, as they have in the past. However, while it is possible to reimagine what is reasonable, the question of responsibility still looms. Who should pay for health care: Should Malawians fund their own care? Or should the funds come from international aid? Do non-governmental organizations have an obligation to improve care regardless of what the Malawian government or international organizations choose to do? As the history of the Central African Federation shows, more spending can raise its own set of issues about sovereignty, local legitimacy, and who is ultimately accountable for providing quality health care.
The question of responsibility underscores the inseparability of health and politics. As No More to Spend shows, health-care spending has largely followed the political winds, rising and falling with popular protests (or a fear of them) as much as foreign aid or economic growth. And so, if spending has always been political, that means that being “unreasonable,” as Messac implores his readers to be, must be approached as a matter of politics too, as a demand for a global standard of care embedded within a broader reimagining of rights and justice in an unequal world. The question of responsibility also means thinking about power, identifying the precise role that policymakers and medical professionals, foreign and Malawian, play in the construction of scarcity, and locating changing notions of “reason” in time, place, and institutions. Messac opens up these questions about reason and responsibility, reimagining the possibilities of care. For anyone interested in the history and future of health care in Malawi and the wider Global South, Messac’s No More to Spend is a must read.
I am profoundly grateful to Alden Young for organizing this roundtable. He has always been an example for me, both as a scholar and as fellow Africanist devoted to building our community. And speaking of that community, I cannot say thank you enough to Elisa Prosperetti, Sarah Runcie, and Geoffrey Traugh for their careful and insightful reviews. I know their contributions here will help further our understanding of the construction of scarcity in medicine (and social services more broadly) in the histories of colonial and postcolonial Africa. Their reviews are, collectively, wide-ranging, but I will try to arrange my comments into something approaching coherence. I am, of course, extremely grateful for their words of appreciation. If the response that follows focuses mostly on their critiques, it is because they were so constructive and considered, and will help to push the literature in new and productive directions.
The first point I will address is not a criticism, but does conjure questions about authorial intent. Traugh and Prosperetti observe that my voice is not neutral. Traugh points to a tradition in Malawian historiography, “which for all its criticism of Banda and the Malawi Congress Party, has taken inspiration from Congress’s late-colonial era slogan—that Malawi was neglected, not poor.” I happily acknowledge I have been deeply influenced by Elias Mandala, Megan Vaughan, and many others who have made the distinction between malign neglect and inevitable poverty before I ever did. The work of these scholars runs rampant through my endnotes.
In the same vein, Prosperetti calls this book a work of “academic activism.” I do not object to this characterization, though I would hasten to add that historians have long eschewed pretensions to a naïve objectivity. As E.H. Carr explained in a series of lectures in 1961, historical works should be imbued with meaning and even lessons for the present. Attempts at a scientistic impartiality lead to a chronicle of dates and events so thorough and without interpretation as to numb the mind. I have no qualms about advocacy in the proper settings, though in my scholarship I remain, as much as possible, faithful to the evidence in the historical record. I strive to ensure that all claims, particularly the most controversial, are well-evidenced. I do not think anyone will find it too unorthodox that I aim, as Allan Brandt put it, “to discover approaches to contemporary social problems in a sophisticated recovery of the past.”
Prosperetti notes that my focus on the political significance of medicine begs questions about the importance of medicine relative to other social services, particularly education. She argues education has been central to retaining political legitimacy in many parts of West Africa. In addition, she points to the fact that Malawian President Bakili Muluzi was widely appreciated for abolishing user fees at government primary schools. In response I would say the relationship between education and popular legitimacy in Malawi is complex, and I cannot do it justice without more study and more space than this forum allows. I am absolutely excited for scholars like Prosperetti and Bekeh Ukelina who are engaging the methodologically challenging and still under-explored issues of the budgetary outlays for and political ramifications of education in colonial and postcolonial African polities. I do not argue that health is singularly important in preserving legitimacy, nor did I aim to pit various social programs against each other in duels of comparative political significance. Still, in Nyasaland, colonial officials often viewed “native” education with ambivalence. Especially after mission-educated preacher John Chilembwe led his 1915 Rising, schools were seen as potential training grounds for subversives. Some historians have argued that Hastings Kamuzu Banda limited opportunities for tertiary education in general (and medical education in particular) for the same reason. Malawi’s particular history of education and unrest may not be generalizable beyond its borders, and I know I have much to learn from Prosperetti’s work.
Each of the reviewers opens up questions about the broader political valences of this work. Prosperetti incisively points out that my focus on the construct of “scarcity” might, to some ears, be a less class-conscious term than “austerity,” which has, in recent decades, been the prime object of critique of the neoliberal approach to social spending. I chose to use the term scarcity more often than austerity because, for much of the period covered by the book, this construct conformed more closely to official claims than what we now commonly understand as austerity. Austerity usually connotes some prior era of fiscal profligacy, of free-spending irresponsibility to be reined in in the name of prudential macroeconomic management. This is certainly how the Bretton Woods institutions discussed “developing countries” during the 1980s as well as southern European nations more recently. But in colonial and early postcolonial Malawi, officials were less likely to claim that spending should be limited in the name of preventing inflation than to insist current spending levels were the absolute limit given Malawi’s aggregate poverty. Scarcity was, in this formulation, not a political choice but an unavoidable reality. The same assumption is as pervasive among the present-day global public health experts quoted in the introduction and conclusion as was among British officials who refused to devote additional funding to fight famine in the 1940s or World Bank officials who would not wage a “mortality control” campaign in the 1960s. It is this persistent insistence that low levels of health spending were inalterable that I sought to interrogate in the book. Even though I still think that there is some analytic value in the distinction between scarcity and austerity, Prosperetti is quite correct that this book is influenced by critics of neoliberal thought.
Runcie offers another helpful provocation, in asking whether we might draw a distinction between those actors in Malawi’s history who simply challenged medical scarcity and those who rendered a more thoroughgoing, fundamental challenge to “the extractive colonial economies that created this scarcity.” There absolutely were such voices. Traugh points out that among these critics were leaders of the Malawi Congress Party during the Federation era. Indeed, one who figured more prominently in my doctoral dissertation than this book was Dunduzu Chisiza, one of the young intellectuals during the party’s early years. He prepared plans for an independent Malawi from his prison cell in Gwelo, in which he called for a wholesale remaking of the economy, including cooperatives and public ownership of monopolies and key industries. He argued against modernization theorists like Walt W. Rostow and W. Arthur Lewis who thought social spending on the ill and the aged should not be a focus of government until industrialization was complete.
Unfortunately, such fundamental critiques of colonial and neocolonial economic arrangements were marginalized. Just as Chisiza’s star was rising in the preparations for independence, he was found dead in a car in a ditch in September 1962. The historian Joey Power has chronicled the rumors and circumstantial evidence that pointed to the future Life President Hastings Kamuzu Banda as the leader of a plot to murder Chisiza in order to fend off any future challenge. These rumors have never been proven. Banda retained much of the economic orthodoxy and policymaking apparatus of the colonial era. Runcie’s work on Cameroon has shown how political officials and health care providers in newly independent Cameroon worked to forge their own path forward for health care, in spite of the agendas of international health organizations and the residual structures of colonial medicine. But Banda, for his part, was often content with continuity in the transition from the colonial to postcolonial eras, a continuity in which European-born doctors and foreign experts retained stature and authority.
The limited influence of radical critics was a large part of the reason for their relatively limited coverage in this history. I focused much of my attention on elite reformists because they were so often the only ones able to gain a hearing with the officials in London or Salisbury or Washington—that is, the officials with power to render resources any less scarce. These reformists’ complaints rarely challenged the basic structure of the economy or governance.
Sometimes acts of protest outside Malawi had an impact on the availability health care within it; such was the case with the Copperbelt strikes of the 1930s or Treatment Action Campaign’s nonviolent agitation for generic production of antiretroviral drugs in South Africa. In recent decades, healthcare providers in sub-Saharan Africa have joined in advocating for a more equitable distribution of the economic resources. They have provided at least part of an answer to Traugh’s trenchant question about who should be responsible for health care financing, given the vexing questions of sovereignty, local legitimacy, and accountability that accompany a reliance on foreign aid and NGOs. Bernadette O’Hare and Mark Curtis, two researchers at Malawi’s College of Medicine, argued in 2014 that the tax revenue lost to illicit financial flows could fund a much more robust system of health care. But for much of the nation’s colonial and postcolonial history, the influence of such voices has been limited. I hope the lesson taken from this rather dismal history is not that efforts seeking to go beyond reformism are fated to failure. The past need not be prologue.
 Stephen Broadberry and Leigh Gardner, “Economic Development in Africa and Europe: Reciprocal Comparisons,” Revista De Historia Económica / Journal of Iberian and Latin American Economic History 34:1 (2016): 11-37, DOI: https://doi.org/10.1017/S0212610915000348. For work criticizing the use of comparative GDP statistics, see: Morten Jerven, Poor Numbers: How We Are Misled by African Development Statistics and What to Do About It? (Ithaca: Cornell University Press, 2013).
 Broadberry and Gardner, “Economic Development in Africa and Europe: Reciprocal Comparisons,”13.
 See the response by Luke Messac at the end of the Roundtable.
 Vanessa Ogle, “‘Funk Money’: The End of Empires, the Expansion of Tax Havens, and Decolonization as a Financial Event,” Past and Present 249:1 (2020): 213-249.
 Walter Rodney, How Europe Underdeveloped Africa, rev. ed. (Washington, D.C.: Howard University Press, 1982), 241.
 Jürgen Habermas, The Structural Transformation of the Public Sphere: An Inquiry into a Category of Bourgeois Society, trans. Thomas Burger (Cambridge: MIT Press, 1991) and Pierre Bourdieu, Acts of Resistance: Against the Tyranny of the Market, trans. Richard Nice (New York: The New Press, 1998).
 James Ferguson, The Anti-Politics Machine: “Development,” Depoliticization, and Bureaucratic Power in Lesotho (New York: Cambridge University Press, 1990).
 Elisa Prosperetti, “Every Available Penny: Expectations, Education and Development in Postcolonial West Africa,” (PhD diss., Princeton University, 2020).
 The World Bank Group, Accelerated Development in Sub-Saharan Africa: An Agenda for Action (Washington, D.C.: The World Bank, 1981), 184.
 Some recent historical works on postindependence medicine include Matthew M. Heaton, Black Skin, White Coats: Nigerian Psychiatrists, Decolonization, and the Globalization of Psychiatry (Athens: Ohio University Press, 2013). John Illife, East African Doctors: A History of the Modern Profession (Cambridge: Cambridge University Press, 2002). Jennifer Tappan, The Riddle of Malnutrition: The Long Arc of Biomedical and Public Health Interventions in Uganda (Athens: Ohio University Press, 2017).
 Examples of relevant works examining post-1980 medicine, including the impact of austerity programs and HIV/AIDS, beyond Malawi include: Meredeth Turshen, Privatizing Health Services in Africa (New Brunswick: Rutgers University Press, 1999). Ellen E. Foley, Your Pocket Is What Cures You: The Politics of Health in Senegal (New Brunswick: Rutgers University Press, 2010). Adia Benton, HIV Exceptionalism: Development through Disease in Sierra Leone (Minneapolis: University of Minnesota Press, 2015).
 Jennifer Johnson, “The Origins of Family Planning in Tunisia: Reform, Public Health, and International Aid,” Bulletin of the History of Medicine 92:4 (Winter 2018): 664–693.
 See, for instance, Elias C. Mandala, The End of Chidyerano: A History of Food and Everyday Life in Malawi, 1860-2004 (Portsmouth: Heinemann, 2005); Megan Vaughan, “Exploitation and Neglect: Rural Producers and the State in Malawi and Zambia,” in History of Central Africa: The Contemporary Years since 1960, edited by David Birmingham and Phyllis M. Martin (London: Longman, 1998): 167-201.
 For other studies of health and medicine in Malawi, see Claire Wendland, A Heart for the Work: Journeys through an African Medical School (Chicago: University of Chicago Press, 2010); Megan Vaughan, Curing their Ills: Colonial Power and African Illness (Stanford: Stanford University Press, 1991).
 On Malawi and the Central African Federation, see John McCracken, A History of Malawi, 1859-1966 (Suffolk: James Currey, 2012). For the diversity of anti-colonial politics and their post-colonial legacies in Malawi, see Owen J. M. Kalinga, “‘The General from Fort Hill’: Katoba Flax Musopole’s Role as an Anti-Colonial Activist and Politician in Malawi,” Journal of Southern African Studies 46 (2020): 301-317; Wapulumuka Oliver Mulwafu, Conservation Song: A History of Peasant-State Relations and the Environment in Malawi, 1860-2000 (Cambridge: White Horse Press, 2011); Joey Power, Political Culture and Nationalism in Malawi: Building Kwacha (Rochester: University of Rochester Press, 2010).
 See, for instance, Elias Mandala, The End of Chidyerano: A History of Food and Everyday Life in Malawi, 1860-2004 (Portsmouth: Heinemann, 2005). Also see Megan Vaughan, The Story of an African Famine in Twentieth-Century Malawi (Cambridge: Cambridge University Press, 2007).
 E.H. Carr, What is History? (Cambridge: University of Cambridge, 1961).
 Allan Brandt, “From Analysis to Advocacy: Crossing Boundaries as a Historian of Medicine,” in Frank Huisman and John Harley Warner, eds., Locating Medical History: The Stories and Their Meanings (Baltimore: Johns Hopkins University Press, 2004).
 Elisa Prosperetti, “Every Available Penny: Expectations, Education, and Development in Postcolonial West Africa,” Ph.D. dissertation, Princeton University, 2020.
 John McCracken, A History of Malawi, 1859-1966 (Woodbridge: James Currey, 2012), 143-144.
 See Claire Wendland, A Heart for the Work: Journeys through the Heart of an African Medical School (Chicago: University of Chicago Press, 2010), 47. Also see John Lwanda, Politics, Culture and Medicine in Malawi: Historical Continuities and Ruptures with Special Reference to HIV/AIDS (Zomba: Kachere, 2005).
 In his landmark history and critique of the concept, political economist Mark Blyth explains that austerity is “a form of voluntary deflation in which the economy adjusts through the reduction in wages, prices, and public spending to restore competitiveness, which is (supposedly) best achieved by cutting the state’s budget, debts and deficits.” Mark Blyth, Austerity: The History of a Dangerous Idea (Oxford: Oxford University Press, 2013).
 See, for instance, Paul Farmer, “The Vitality of Practice: On Personal Trajectories,” in Infections and Inequalities: The Modern Plagues, 18-36 (Berkeley: University of California Press, 1999); Salmaan Keshavjee, Blind Spot: How Neoliberalism Infiltrated Global Health (Berkeley: University of California Press, 2014).
 Dunduzu Chisiza, Realities of African Independence (London: The Africa Publications Trust, 1961).
 Joey Power, Political Culture and Nationalism in Malawi: Building Kwacha (Rochester: University of Rochester Press, 2010)
 Sarah Cook Runcie, “From Malaria Eradication to Basic Health Services: Decolonization and Public Health Futures in 1960s Cameroon,” International Journal of African Historical Studies 53:1 (2020): 27-46.
 Bernadette O’Hare and Mark Curtis, “Health Spending, Illicit Financial Flows and Tax Incentives in Malawi,” Malawi Medical Journal 26:4 (2014): 133-137.